At AMA confab, consensus seen on care-team leadership

It's unclear how members of the American Medical Association House of Delegates will vote this week on some of the major policy questions raised over the weekend, but it appeared that there was consensus on at least two points: Physicians should be the leaders of healthcare teams and, when it comes to interstate telemedicine, the point of care is the patient's location—not the doctor's.

Delegates debated the merits of more than 250 reports and resolutions Sunday in eight separate reference committee hearings. Four panels met in the morning with the other four meeting in the afternoon. Doctors crisscrossed the subterranean hallways of the Hyatt Regency Chicago, going from one room to another in order to weigh in on their topic of interest.

Among the items on the agenda of the committee dealing with medical practice and facility issues was a report from the AMA Council on Medical Service seeking to clarify the elements of on emerging inter-professional healthcare teams.

The report cited AMA policy in declaring that the “unwavering principle that clinical care teams should be physician-led helps guide the activities of the AMA, as well as AMA initiatives.” The AMA and American Academy of Family Physicians have issued similar declarations before and subsequently came under fire from nurses and nurse practitioners for being out of touch.

The AMA and AAFP have not received any public support on the issue of physician healthcare team leadership, as none of the major organizations that accredit, recognize or certify practices as patient-centered medical homes include physician leadership as a requirement for receiving recognition.

This includes the Joint Commission's Primary Care Medical Home Certification program, which has certified 1,138 sites (PDF) as having successfully implemented the care-coordination, increased access and communication, and continuous quality improvement aspects of the medical home practice model.

While the Council on Medical Service report had been on the agenda for some time—having been ordered by the House of Delegates at last year's meeting—a late, related resolution had been added to the schedule just the day before.

The resolution was in response to a Frequently Asked Questions page added June 3 to the Joint Commission website's section explaining its primary-care medical home certification program. The document includes a reaffirmation of the Joint Commission's position on not requiring physician leadership.

“The Joint Commission will continue to certify nurse-led PCMHs,” the FAQ page stats. “The standards changes do not impose any restrictions on the scope of practice of individuals serving as primary care clinicians (PCC), nor do they preempt applicable state law.”

The resolution called for the AMA to continue to support the concept of physician-led teams, to respond to the Joint Commission, and to conduct a study on comparing physician-led and nonphysician-led medical homes in terms of quality of care, per patient expenditures, total healthcare costs, access to care and patient outcomes.

Former AMA Board Chairwoman Dr. Rebecca Patchin, who was a nurse before becoming an anesthesiologist, now chairs the Joint Commission board and she addressed the committee.

“This has been contentious,” Patchin said, but she noted that there are 16 physicians and only five nurses on the Joint Commission's 32-person board, so decisions are not made without doctors' input.

“How can you have a medical home without a physician?” Willson argued. “It should be patient-centered and physician-led.”

Patient-centeredness was also part of a discussion on telemedicine issues. There is ongoing debate over whether the point of care is the location of the patient or the location of the doctor, and the resolution of the argument has serious implications for medical licensing.

The current standard is that the point of care is the patient's location, so physicians who practice via telephone, computer portal, video conference or some other telemedicine modality are required to be licensed in the state where their patients are located.

That standard has been followed by organizations with extensive telemedicine services such as the Mayo Clinic and the Dallas-based telemedicine provider Teledoc, but it's noted that following this rule adds expense and delays access to underserved areas as physicians go through the licensing process.

This standard is also included in the AMA's policy on telemedicine which states that “medical boards of states and territories should require a full and unrestricted license in that state for the practice of telemedicine … with no differentiation by specialty, for physicians who wish to practice telemedicine in that state or territory.”

At a telemedicine forum held the morning before the official start of the House of Delegates meeting on Saturday, it was noted that the AMA opposes a federal medical license, but supports efforts to standardize and modernize state-based medical license processing.

Dr. James Sabin, a clinical professor at Harvard Medical School and a member of the AMA Council on Ethical and Judicial Affairs, noted “there is a fair amount of flim-flam happening” with telemedicine, so patients need to know who is on the other end of the connection. A Council on Medical Service report recommends that patients have access to the license and board certification of their telemedicine provider and patients must not be required to see a telemedicine provider if they prefer a traditional visit.

The House of Delegates will be voting Monday through Wednesday on the recommendations of the reports and resolutions.